Why is meat consumption a risk factor for diabetes? Why does there appear to be a stepwise reduction in diabetes rates as meat consumption drops? Instead of avoiding something in meat, it may be that people are getting something protective from plants. Free radicals may be an important trigger for insulin resistance, and antioxidants in plant foods may help. Put people on a plant-based diet, and their antioxidant enzymes shoot up. So not only do plants provide antioxidants, but may boost our own anti-endogenous antioxidant defenses, whereas, on the conventional diabetic diet, they get worse.

In my video, How May Plants Protect Against Diabetes, I discuss how there are phytonutrients in plant foods that may help lower chronic disease prevalence by acting as antioxidants and anti-cancer agents, and by lowering cholesterol and blood sugar. Some, we're now theorizing, may even be lipotropes, which have the capacity to hasten the removal of fat from our liver and other organs, counteracting the inflammatory cascade believed to be directly initiated by saturated-fat-containing foods. Fat in the bloodstream--from the fat on our bodies or the fat we eat--not only causes insulin resistance, but also produces a low-grade inflammation that can contribute to heart disease and non-alcoholic fatty liver disease.

Fiber may also decrease insulin resistance. One of the ways it may do so is by helping to rid the body of excess estrogen. There is strong evidence for a direct role of estrogens in the cause of diabetes, and it's been demonstrated that certain gut bacteria can produce estrogens in our colon. High-fat, low-fiber diets appear to stimulate the metabolic activity of these estrogen-producing intestinal bacteria. This is a problem for men, too. Obesity is associated with low testosterone levels and marked elevations of estrogens produced not only by fat cells but also by some of the bacteria in our gut. Our intestinal bacteria may produce these so-called diabetogens (diabetes-causing compounds) from the fats we eat. By eating lots of fiber, though, we can flush this excess estrogen out of our bodies.

Vegetarian women, for example, excrete two to three times more estrogens in their stools than omnivorous women, which may be why omnivorous women have 50% higher estrogen blood levels. These differences in estrogen metabolism may help explain the lower incidence of diabetes in those eating more plant-based diets, as well as the lower incidence of breast cancer in vegetarian women, who get rid of twice as much estrogen because they get rid of twice as much daily waste in general.

Either way, "[m]eat consumption is consistently associated with diabetes risk. Dietary habits are readily modifiable, but individuals and clinicians will consider dietary changes only if they are aware of the potential benefits of doing so." The identification of meat consumption as a risk factor for diabetes provides helpful guidance that sets the stage for beneficial behavioral changes. Meat consumption is something doctors can easily ask about, and, once identified, at-risk individuals can then be encouraged to familiarize themselves with meatless options.

Why is meat consumption a risk factor for diabetes? Why does there appear to be a stepwise reduction in diabetes rates as meat consumption drops? Instead of avoiding something in meat, it may be that people are getting something protective from plants. Free radicals may be an important trigger for insulin resistance, and antioxidants in plant foods may help. Put people on a plant-based diet, and their antioxidant enzymes shoot up. So not only do plants provide antioxidants, but may boost our own anti-endogenous antioxidant defenses, whereas, on the conventional diabetic diet, they get worse.

In my video, How May Plants Protect Against Diabetes, I discuss how there are phytonutrients in plant foods that may help lower chronic disease prevalence by acting as antioxidants and anti-cancer agents, and by lowering cholesterol and blood sugar. Some, we're now theorizing, may even be lipotropes, which have the capacity to hasten the removal of fat from our liver and other organs, counteracting the inflammatory cascade believed to be directly initiated by saturated-fat-containing foods. Fat in the bloodstream--from the fat on our bodies or the fat we eat--not only causes insulin resistance, but also produces a low-grade inflammation that can contribute to heart disease and non-alcoholic fatty liver disease.

Fiber may also decrease insulin resistance. One of the ways it may do so is by helping to rid the body of excess estrogen. There is strong evidence for a direct role of estrogens in the cause of diabetes, and it's been demonstrated that certain gut bacteria can produce estrogens in our colon. High-fat, low-fiber diets appear to stimulate the metabolic activity of these estrogen-producing intestinal bacteria. This is a problem for men, too. Obesity is associated with low testosterone levels and marked elevations of estrogens produced not only by fat cells but also by some of the bacteria in our gut. Our intestinal bacteria may produce these so-called diabetogens (diabetes-causing compounds) from the fats we eat. By eating lots of fiber, though, we can flush this excess estrogen out of our bodies.

Vegetarian women, for example, excrete two to three times more estrogens in their stools than omnivorous women, which may be why omnivorous women have 50% higher estrogen blood levels. These differences in estrogen metabolism may help explain the lower incidence of diabetes in those eating more plant-based diets, as well as the lower incidence of breast cancer in vegetarian women, who get rid of twice as much estrogen because they get rid of twice as much daily waste in general.

Either way, "[m]eat consumption is consistently associated with diabetes risk. Dietary habits are readily modifiable, but individuals and clinicians will consider dietary changes only if they are aware of the potential benefits of doing so." The identification of meat consumption as a risk factor for diabetes provides helpful guidance that sets the stage for beneficial behavioral changes. Meat consumption is something doctors can easily ask about, and, once identified, at-risk individuals can then be encouraged to familiarize themselves with meatless options.

Diverticula are out-pouchings of our intestine. Doctors like using a tire analogy: high pressures within the gut can force the intestines to balloon out through weak spots in the intestinal wall like an inner tube poking out through a worn tire tread. You can see what they actually look like in my video, Diverticulosis: When Our Most Common Gut Disorder Hardly Existed. These pockets can become inflamed and infected, and, to carry the tire analogy further, can blow out and spill fecal matter into the abdomen, and lead to death. Symptoms can range from no symptoms at all, to a little cramping and bloating, to "incapacitating pain that is a medical emergency." Nine out of ten people who die from the disease never even knew they had it.

The good news is there may be a way to prevent the disease. Diverticular disease is the most common intestinal disorder, affecting up to 70% of people by age 60. If it's that common, though, is it just an inevitable consequence of aging? No, it's a new disease. In 1907, 25 cases had been reported in the medical literature. Not cases in 25% of people, but 25 cases period. And diverticular disease is kind of hard to miss on autopsy. A hundred years ago, in 1916, it didn't even merit mention in medical and surgical textbooks. The mystery wasn't solved until 1971.

How did a disease that was almost unknown become the most common affliction of the colon in the Western world within one lifespan? Surgeons Painter and Burkitt suggested diverticulosis was a deficiency disease--i.e., a disease caused by a deficiency of fiber. In the late 1800s, roller milling was introduced, further removing fiber from grain, and we started to fill up on other fiber-deficient foods like meat and sugar. A few decades of this and diverticulosis was rampant.

This is what Painter and Burkitt thought was going on: Just as it would be easy to squeeze a lump of butter through a bicycle tube, it's easy to move large, soft, and moist intestinal contents through the gut. In contrast, try squeezing through a lump of tar. When we eat fiber-deficient diets, our feces can become small and firm, and our intestines have to really squeeze down hard to move them along. This buildup of pressure may force out those bulges. Eventually, a low-fiber diet can sometimes lead to the colon literally rupturing itself.

If this theory is true, then populations eating high­-fiber diets would have low rates of diverticulosis. That's exactly what's been found. More than 50% of African Americans in their 50s were found to have diverticulosis, compared to less than 1% in African Africans eating traditional plant-based diets. By less than 1%, we're talking zero out of a series of 2,000 autopsies in South Africa and two out of 4,000 in Uganda. That's about one thousand times lower prevalence.

Diverticula are out-pouchings of our intestine. Doctors like using a tire analogy: high pressures within the gut can force the intestines to balloon out through weak spots in the intestinal wall like an inner tube poking out through a worn tire tread. You can see what they actually look like in my video, Diverticulosis: When Our Most Common Gut Disorder Hardly Existed. These pockets can become inflamed and infected, and, to carry the tire analogy further, can blow out and spill fecal matter into the abdomen, and lead to death. Symptoms can range from no symptoms at all, to a little cramping and bloating, to "incapacitating pain that is a medical emergency." Nine out of ten people who die from the disease never even knew they had it.

The good news is there may be a way to prevent the disease. Diverticular disease is the most common intestinal disorder, affecting up to 70% of people by age 60. If it's that common, though, is it just an inevitable consequence of aging? No, it's a new disease. In 1907, 25 cases had been reported in the medical literature. Not cases in 25% of people, but 25 cases period. And diverticular disease is kind of hard to miss on autopsy. A hundred years ago, in 1916, it didn't even merit mention in medical and surgical textbooks. The mystery wasn't solved until 1971.

How did a disease that was almost unknown become the most common affliction of the colon in the Western world within one lifespan? Surgeons Painter and Burkitt suggested diverticulosis was a deficiency disease--i.e., a disease caused by a deficiency of fiber. In the late 1800s, roller milling was introduced, further removing fiber from grain, and we started to fill up on other fiber-deficient foods like meat and sugar. A few decades of this and diverticulosis was rampant.

This is what Painter and Burkitt thought was going on: Just as it would be easy to squeeze a lump of butter through a bicycle tube, it's easy to move large, soft, and moist intestinal contents through the gut. In contrast, try squeezing through a lump of tar. When we eat fiber-deficient diets, our feces can become small and firm, and our intestines have to really squeeze down hard to move them along. This buildup of pressure may force out those bulges. Eventually, a low-fiber diet can sometimes lead to the colon literally rupturing itself.

If this theory is true, then populations eating high­-fiber diets would have low rates of diverticulosis. That's exactly what's been found. More than 50% of African Americans in their 50s were found to have diverticulosis, compared to less than 1% in African Africans eating traditional plant-based diets. By less than 1%, we're talking zero out of a series of 2,000 autopsies in South Africa and two out of 4,000 in Uganda. That's about one thousand times lower prevalence.

Irritable bowel syndrome (IBS) is a chronic, episodic intestinal disorder characterized by abdominal pain and altered bowel habits. It affects 1 in 7 Americans, although most go undiagnosed. IBS can have a substantial impact on well-being and health, but doctors underestimate the impact the disease can have, particularly the pain and discomfort. Using some measures, the health-related quality of life of irritable bowel sufferers can rival that of sufferers of much more serious disorders, such as diabetes, kidney failure, and inflammatory bowel diseases. The first step toward successful treatment is for doctors to acknowledge the condition and not just dismiss the patient as just hysterical or something.

Another reason sufferers often don't seek medical care may be the lack of effectiveness of the available treatments. There is a huge unmet therapeutic need. Since IBS has no cure, treatment is targeted to alleviate the symptoms. Typical antispasmodic drugs can cause side effects, including dry mouth, dizziness, blurred vision, confusion, and fall risk. New drugs now on the market, like Lubiprostone and Linaclotide, can cost up to $3,000 a year and can cause as side effects many of symptoms we're trying to treat.

Antidepressants are commonly given but may take weeks or even months to start helping. Prozac or Celexa take 4 to 6 weeks to help, and Paxil can take up to 12 weeks. They also have their own array of side effects, including sexual dysfunction in over 70% of the people who take these drugs.

There's got to be a better way.

Acupuncture works, but not better than placebo. Placebo acupuncture? That's where you poke people with a fake needle away from any known acupuncture points. Yet that worked just as well as real acupuncture, showing the power of the placebo effect.

I've talked about the ethics of so many doctors who effectively pass off sugar pills as effective drugs, arguing that the ends justify their means. There's actually a way to harness the placebo effect without lying to patients, though. We tell them it's a sugar pill. Patients with irritable bowel syndrome were randomized to either get nothing or a prescription medicine bottle of placebo pills with a label clearly marked "placebo pills" "take 2 pills twice daily." I kid you not.

Lo and behold, it worked! That's how powerful the placebo effect can be for irritable bowel. They conclude that for some disorders it may be appropriate for clinicians to recommend that patients try an inexpensive and safe placebo. Indeed, sugar pills probably won't cost $3,000 a year. But is there a safe alternative that actually works?

As you can see in my video, Peppermint Oil for Irritable Bowel Syndrome, nine randomized placebo-controlled studies have indeed found peppermint oil to be a safe and effective treatment for irritable bowel syndrome. A few adverse events were reported, but were mild and transient in nature, such as a peppermint taste, peppermint smell, and a cooling sensation around one's bottom on the way out. In contrast, in some of the head-to-head peppermint versus drug studies, some of the drug side effects were so unbearable that patients had to drop out of the study. This suggests it might be a reasonable approach for clinicians to treat IBS patients with peppermint oil as a first-line therapy, before trying anything else.

The longest trial only lasted 12 weeks, so we don't yet know about long-term efficacy. The benefits may last at least a month after stopping, though, perhaps due to lasting changes in our gut flora.

The studies used peppermint oil capsules so researchers could match them with placebo pills. What about peppermint tea? It's never been tested, but one might assume it wouldn't be concentrated enough. However, a quarter cup of fresh peppermint leaves has as much peppermint oil as some of the capsule doses used in the studies. One could easily blend it into a smoothie or with frozen berries to make something like my pink juice recipe. You can grow mint right on your window sill.

We doctors need effective treatments that "are cheap, safe, and readily available. This is particularly relevant at the present time as newer and more expensive drugs have either failed to show efficacy or been withdrawn from the market owing to concerns about serious adverse events." Just like it may be a good idea to only eat foods with ingredients you can pronounce, it may be better to try some mint before novel pharmacological approaches, such the new dual mu-opioid agonist delta-antagonist drug with a name like JNJ-27018966.

Irritable bowel syndrome (IBS) is a chronic, episodic intestinal disorder characterized by abdominal pain and altered bowel habits. It affects 1 in 7 Americans, although most go undiagnosed. IBS can have a substantial impact on well-being and health, but doctors underestimate the impact the disease can have, particularly the pain and discomfort. Using some measures, the health-related quality of life of irritable bowel sufferers can rival that of sufferers of much more serious disorders, such as diabetes, kidney failure, and inflammatory bowel diseases. The first step toward successful treatment is for doctors to acknowledge the condition and not just dismiss the patient as just hysterical or something.

Another reason sufferers often don't seek medical care may be the lack of effectiveness of the available treatments. There is a huge unmet therapeutic need. Since IBS has no cure, treatment is targeted to alleviate the symptoms. Typical antispasmodic drugs can cause side effects, including dry mouth, dizziness, blurred vision, confusion, and fall risk. New drugs now on the market, like Lubiprostone and Linaclotide, can cost up to $3,000 a year and can cause as side effects many of symptoms we're trying to treat.

Antidepressants are commonly given but may take weeks or even months to start helping. Prozac or Celexa take 4 to 6 weeks to help, and Paxil can take up to 12 weeks. They also have their own array of side effects, including sexual dysfunction in over 70% of the people who take these drugs.

There's got to be a better way.

Acupuncture works, but not better than placebo. Placebo acupuncture? That's where you poke people with a fake needle away from any known acupuncture points. Yet that worked just as well as real acupuncture, showing the power of the placebo effect.

I've talked about the ethics of so many doctors who effectively pass off sugar pills as effective drugs, arguing that the ends justify their means. There's actually a way to harness the placebo effect without lying to patients, though. We tell them it's a sugar pill. Patients with irritable bowel syndrome were randomized to either get nothing or a prescription medicine bottle of placebo pills with a label clearly marked "placebo pills" "take 2 pills twice daily." I kid you not.

Lo and behold, it worked! That's how powerful the placebo effect can be for irritable bowel. They conclude that for some disorders it may be appropriate for clinicians to recommend that patients try an inexpensive and safe placebo. Indeed, sugar pills probably won't cost $3,000 a year. But is there a safe alternative that actually works?

As you can see in my video, Peppermint Oil for Irritable Bowel Syndrome, nine randomized placebo-controlled studies have indeed found peppermint oil to be a safe and effective treatment for irritable bowel syndrome. A few adverse events were reported, but were mild and transient in nature, such as a peppermint taste, peppermint smell, and a cooling sensation around one's bottom on the way out. In contrast, in some of the head-to-head peppermint versus drug studies, some of the drug side effects were so unbearable that patients had to drop out of the study. This suggests it might be a reasonable approach for clinicians to treat IBS patients with peppermint oil as a first-line therapy, before trying anything else.

The longest trial only lasted 12 weeks, so we don't yet know about long-term efficacy. The benefits may last at least a month after stopping, though, perhaps due to lasting changes in our gut flora.

The studies used peppermint oil capsules so researchers could match them with placebo pills. What about peppermint tea? It's never been tested, but one might assume it wouldn't be concentrated enough. However, a quarter cup of fresh peppermint leaves has as much peppermint oil as some of the capsule doses used in the studies. One could easily blend it into a smoothie or with frozen berries to make something like my pink juice recipe. You can grow mint right on your window sill.

We doctors need effective treatments that "are cheap, safe, and readily available. This is particularly relevant at the present time as newer and more expensive drugs have either failed to show efficacy or been withdrawn from the market owing to concerns about serious adverse events." Just like it may be a good idea to only eat foods with ingredients you can pronounce, it may be better to try some mint before novel pharmacological approaches, such the new dual mu-opioid agonist delta-antagonist drug with a name like JNJ-27018966.

Irritable bowel syndrome (IBS) is a chronic, episodic intestinal disorder characterized by abdominal pain and altered bowel habits. It affects 1 in 7 Americans, although most go undiagnosed. IBS can have a substantial impact on well-being and health, but doctors underestimate the impact the disease can have, particularly the pain and discomfort. Using some measures, the health-related quality of life of irritable bowel sufferers can rival that of sufferers of much more serious disorders, such as diabetes, kidney failure, and inflammatory bowel diseases. The first step toward successful treatment is for doctors to acknowledge the condition and not just dismiss the patient as just hysterical or something.

Another reason sufferers often don't seek medical care may be the lack of effectiveness of the available treatments. There is a huge unmet therapeutic need. Since IBS has no cure, treatment is targeted to alleviate the symptoms. Typical antispasmodic drugs can cause side effects, including dry mouth, dizziness, blurred vision, confusion, and fall risk. New drugs now on the market, like Lubiprostone and Linaclotide, can cost up to $3,000 a year and can cause as side effects many of symptoms we're trying to treat.

Antidepressants are commonly given but may take weeks or even months to start helping. Prozac or Celexa take 4 to 6 weeks to help, and Paxil can take up to 12 weeks. They also have their own array of side effects, including sexual dysfunction in over 70% of the people who take these drugs.

There's got to be a better way.

Acupuncture works, but not better than placebo. Placebo acupuncture? That's where you poke people with a fake needle away from any known acupuncture points. Yet that worked just as well as real acupuncture, showing the power of the placebo effect.

I've talked about the ethics of so many doctors who effectively pass off sugar pills as effective drugs, arguing that the ends justify their means. There's actually a way to harness the placebo effect without lying to patients, though. We tell them it's a sugar pill. Patients with irritable bowel syndrome were randomized to either get nothing or a prescription medicine bottle of placebo pills with a label clearly marked "placebo pills" "take 2 pills twice daily." I kid you not.

Lo and behold, it worked! That's how powerful the placebo effect can be for irritable bowel. They conclude that for some disorders it may be appropriate for clinicians to recommend that patients try an inexpensive and safe placebo. Indeed, sugar pills probably won't cost $3,000 a year. But is there a safe alternative that actually works?

As you can see in my video, Peppermint Oil for Irritable Bowel Syndrome, nine randomized placebo-controlled studies have indeed found peppermint oil to be a safe and effective treatment for irritable bowel syndrome. A few adverse events were reported, but were mild and transient in nature, such as a peppermint taste, peppermint smell, and a cooling sensation around one's bottom on the way out. In contrast, in some of the head-to-head peppermint versus drug studies, some of the drug side effects were so unbearable that patients had to drop out of the study. This suggests it might be a reasonable approach for clinicians to treat IBS patients with peppermint oil as a first-line therapy, before trying anything else.

The longest trial only lasted 12 weeks, so we don't yet know about long-term efficacy. The benefits may last at least a month after stopping, though, perhaps due to lasting changes in our gut flora.

The studies used peppermint oil capsules so researchers could match them with placebo pills. What about peppermint tea? It's never been tested, but one might assume it wouldn't be concentrated enough. However, a quarter cup of fresh peppermint leaves has as much peppermint oil as some of the capsule doses used in the studies. One could easily blend it into a smoothie or with frozen berries to make something like my pink juice recipe. You can grow mint right on your window sill.

We doctors need effective treatments that "are cheap, safe, and readily available. This is particularly relevant at the present time as newer and more expensive drugs have either failed to show efficacy or been withdrawn from the market owing to concerns about serious adverse events." Just like it may be a good idea to only eat foods with ingredients you can pronounce, it may be better to try some mint before novel pharmacological approaches, such the new dual mu-opioid agonist delta-antagonist drug with a name like JNJ-27018966.

Compared to rural African populations eating traditional plant-based diets, white South Africans and black and white Americans have more than 50 times more heart disease, 10 times more colon cancer, more than 50 times more gallstones and appendicitis, and more than 25 times the rates of "pressure diseases"--diverticulitis, hemorrhoids, varicose veins, and hiatal hernia.

As I discussed in my Should You Sit, Squat, or Lean During a Bowel Movement?, bowel movements should be effortless. When we have to strain at stool, the pressure may balloon out-pouchings from our colon, causing diverticulosis; inflate hemorrhoids around the anus; cause the valves in the veins of our legs to fail, causing varicose veins; and even force part of the stomach up through the diaphragm into our chest cavity, causing a hiatal hernia (as I covered previously). When this was first proposed by Dr. Denis Burkitt, he blamed these conditions on the straining caused by a lack of fiber in the diet. He did, however, acknowledge there were alternative explanations. For example, in rural Africa, they used a traditional squatting position when they defecated, which may have taken off some of the pressure.

For hundreds of thousands of years, everyone used the squatting position, which may help by straightening the "anorectal angle." There's actually a kink at almost a 90-degree angle right at the end of the rectum that helps keep us from pooping our pants when we're just out walking around. That angle only slightly straightens out in a common sitting posture on the toilet. Maximal straightening out of this angle occurs in a squatting posture, potentially permitting smoother defecation. (I remember sitting in geometry class wondering when I'd ever use the stuff I was learning. Little did I know I would one day be calculating anorectal angles with it! Stay in school, kids :)

How did they figure this out? Researchers filled latex tubes with a radiopaque fluid, stuck them up some volunteers, and took X-rays with the hips flexed at various angles. They concluded that flexing the knees towards the chest like one does when squatting may straighten that angle and reduce the amount of pressure needed to empty the rectum. This idea wasn't directly put to the test until 2002, when researchers used defecography (which are X-rays taken while the person is defecating) on subjects in sitting and squatting positions. Indeed, squatting increased the anorectal angle from around 90 degrees all the way up to about 140.

So should we all get one of those little stools for our stools, like the Squatty Potty that you put in front of your toilet to step on? No, they don't seem to work. Researchers tried adding a footstool to decrease sitting height, but it didn't seem to significantly affect the time it took to empty one's bowels or decrease the difficulty of defecating. They tried even higher footstools, but people complained of extreme discomfort using them. Nothing seemed to compare with actual squatting, which may give the maximum advantage. However, in developed nations, it may not be convenient. But, we can achieve a similar effect by leaning forward as we sit, with our hands on or near the floor. The researchers advise all sufferers from constipation to adopt this forward-leaning position when defecating, as the weight of our torso pressing against the thighs may put an extra squeeze on our colons.

Instead of finding ways to add more pressure, why not get to the root of the problem? "The fundamental cause of straining is the effort required to pass unnaturally firm stools." By manipulating the anorectal angle through squatting or leaning, we can more easily pass unnaturally firm stools. But why not just treat the cause and eat enough fiber-containing whole plant foods to create stools so large and soft that you could pass them effortlessly at any angle?

Famed cardiologist Dr. Joel Kahn once said that you know you know you're eating a plant-based diet when "you take longer to pee than to poop."

In all seriousness, even squatting does not significantly decrease the pressure gradient that may cause a hiatal hernia. It does not prevent the pressure transmission down into the legs that may cause varicose veins. And this is not just a cosmetic issue. Protracted straining can cause heart rhythm disturbances and reduction in blood flow to the heart and brain, resulting in defecation-related fainting and death. Just 15 seconds of straining can temporarily cut blood flow to the brain by 21% and blood flow to the heart by nearly one-half, thereby providing a mechanism for the well-known "bed pan death" syndrome. If you think you have to strain a lot while sitting, try having a bowel movement on your back. Bearing down for just a few seconds can send our blood pressure up to nearly 170 over 110, which may help account for the notorious frequency of sudden and unexpected deaths of patients while using bed pans in hospitals. Hopefully, if we eat healthy enough, we won't end up in the hospital to begin with.

Compared to rural African populations eating traditional plant-based diets, white South Africans and black and white Americans have more than 50 times more heart disease, 10 times more colon cancer, more than 50 times more gallstones and appendicitis, and more than 25 times the rates of "pressure diseases"--diverticulitis, hemorrhoids, varicose veins, and hiatal hernia.

As I discussed in my Should You Sit, Squat, or Lean During a Bowel Movement?, bowel movements should be effortless. When we have to strain at stool, the pressure may balloon out-pouchings from our colon, causing diverticulosis; inflate hemorrhoids around the anus; cause the valves in the veins of our legs to fail, causing varicose veins; and even force part of the stomach up through the diaphragm into our chest cavity, causing a hiatal hernia (as I covered previously). When this was first proposed by Dr. Denis Burkitt, he blamed these conditions on the straining caused by a lack of fiber in the diet. He did, however, acknowledge there were alternative explanations. For example, in rural Africa, they used a traditional squatting position when they defecated, which may have taken off some of the pressure.

For hundreds of thousands of years, everyone used the squatting position, which may help by straightening the "anorectal angle." There's actually a kink at almost a 90-degree angle right at the end of the rectum that helps keep us from pooping our pants when we're just out walking around. That angle only slightly straightens out in a common sitting posture on the toilet. Maximal straightening out of this angle occurs in a squatting posture, potentially permitting smoother defecation. (I remember sitting in geometry class wondering when I'd ever use the stuff I was learning. Little did I know I would one day be calculating anorectal angles with it! Stay in school, kids :)

How did they figure this out? Researchers filled latex tubes with a radiopaque fluid, stuck them up some volunteers, and took X-rays with the hips flexed at various angles. They concluded that flexing the knees towards the chest like one does when squatting may straighten that angle and reduce the amount of pressure needed to empty the rectum. This idea wasn't directly put to the test until 2002, when researchers used defecography (which are X-rays taken while the person is defecating) on subjects in sitting and squatting positions. Indeed, squatting increased the anorectal angle from around 90 degrees all the way up to about 140.

So should we all get one of those little stools for our stools, like the Squatty Potty that you put in front of your toilet to step on? No, they don't seem to work. Researchers tried adding a footstool to decrease sitting height, but it didn't seem to significantly affect the time it took to empty one's bowels or decrease the difficulty of defecating. They tried even higher footstools, but people complained of extreme discomfort using them. Nothing seemed to compare with actual squatting, which may give the maximum advantage. However, in developed nations, it may not be convenient. But, we can achieve a similar effect by leaning forward as we sit, with our hands on or near the floor. The researchers advise all sufferers from constipation to adopt this forward-leaning position when defecating, as the weight of our torso pressing against the thighs may put an extra squeeze on our colons.

Instead of finding ways to add more pressure, why not get to the root of the problem? "The fundamental cause of straining is the effort required to pass unnaturally firm stools." By manipulating the anorectal angle through squatting or leaning, we can more easily pass unnaturally firm stools. But why not just treat the cause and eat enough fiber-containing whole plant foods to create stools so large and soft that you could pass them effortlessly at any angle?

Famed cardiologist Dr. Joel Kahn once said that you know you know you're eating a plant-based diet when "you take longer to pee than to poop."

In all seriousness, even squatting does not significantly decrease the pressure gradient that may cause a hiatal hernia. It does not prevent the pressure transmission down into the legs that may cause varicose veins. And this is not just a cosmetic issue. Protracted straining can cause heart rhythm disturbances and reduction in blood flow to the heart and brain, resulting in defecation-related fainting and death. Just 15 seconds of straining can temporarily cut blood flow to the brain by 21% and blood flow to the heart by nearly one-half, thereby providing a mechanism for the well-known "bed pan death" syndrome. If you think you have to strain a lot while sitting, try having a bowel movement on your back. Bearing down for just a few seconds can send our blood pressure up to nearly 170 over 110, which may help account for the notorious frequency of sudden and unexpected deaths of patients while using bed pans in hospitals. Hopefully, if we eat healthy enough, we won't end up in the hospital to begin with.

In terms of preventing acid reflux heartburn, high-fat meals cause dramatically more acid exposure in the esophagus in the hours after a meal. I talked about this in Diet and GERD Acid Reflux Heartburn. High fiber intake decreases the risk, but why? One typically thinks of fiber as helping out much lower in the digestive tract.

A systematic review and meta-analysis published in 2013 found a highly significant protective association between esophageal adenocarcinoma and dietary fiber intake, suggesting that individuals with the highest fiber intakes have an approximately 30% lower risk of cancer. This could be because of the phytates in high-fiber foods slowing cancer growth, fiber's anti-inflammatory effects, or even fiber removing carcinogens. But those are all generic anti-cancer effects of whole plant foods. Specific to this type of acid irritation-induced esophageal cancer, fiber may reduce the risk of reflux in the first place. But how?

As you can see in my video, Diet and Hiatal Hernia, hiatus hernia occurs when part of the stomach is pushed up through the diaphragm into the chest cavity, which makes it easy for acid to reflux into the esophagus and throat. Hiatus hernia affects more than 1 in 5 American adults. In contrast, in rural African communities eating their traditional plant-based diets, the risk wasn't 1 in 5; it was closer to 1 in 1,000--almost unheard of. Hiatus hernia is almost peculiar to those who consume western-type diets. Why are plant-based populations protected? Perhaps because they pass such large, soft stools, three or four times the volume as Westerners.

What does the size and consistency of one's bowel movement have to do with hiatal hernia? A simple model may be helpful in illustrating the mechanism that produces upward herniation of the stomach through the hole (called the esophageal hiatus) in the diaphragm, which separates the abdomen from the chest. If a ball with a hole in its wall is filled with water and then squeezed, the water is pushed out through the hole. If we liken the abdominal cavity to the ball, the esophageal hiatus in the diaphragm corresponds with the hole in the ball. Abdominal straining during movement of firm feces corresponds to squeezing the ball and may result in the gradual expulsion of the upper end of the stomach from the abdominal cavity up into the chest. It's like when we squeeze a stress ball. Straining at stool raises pressures inside our abdominal cavity more than almost any other factor.

In effect, straining at stool puts the squeeze on our abdomen and may herniate part of our stomach up. "Consistent with this concept is the observation that in Africans the lower esophageal sphincter is entirely subdiaphragmatic, whereas it usually straddles the diaphragm in Westerners and is above the diaphragm in the presence of hiatus hernia."

This same abdominal pressure from straining may cause a number of other problems, too. Straining can cause herniations in the wall of the colon itself, known as diverticulosis. That same pressure can backup blood flow in the veins around the anus, causing hemorrhoids, and also push blood flow back into the legs, resulting in varicose veins.

Hiatal hernia is not the only condition that high-fiber diets may protect against. See: